Students, faculty, and institutions are applying computer technology to modern medical practice more than ever before. However, a curriculum or method of teaching computer technology as it relates to medical practice has not yet been established. In this information age, portable technology such as CDs and web-based resources allows us to interactively learn at our convenience. E-mail, telecommuting, and the Internet (e.g., movies and music) have radically altered our lives at work and home. Medical educators must assess these technological developments carefully in order to make best use of them. Medical educators should also prepare for future useful advances in technology while avoiding technological development that might not be applicable to the medical field.
Medical informatics is one of nine objectives in the Council on Graduate Medical Education for the Undergraduate Medical Education for the 21st Century (UME-21) curriculum project (1). It "… is the science underlying the acquisition, maintenance, retrieval and application of biomedical knowledge and information to improve patient care, education, research and administration" (2). It is increasingly clear that computers help us to systematically respond to problems (3). Many students, faculty, and institutions have applied the principles and techniques of computer technology to medical education as well as life-long learning.
Psychiatrists are in a unique position to use and evaluate technology since the content and process of therapy are conducive to technological learning and adaptation. The field, however, appears to be struggling to find and maintain a comfortable relationship to medical informatics. Presently, students and interns are often more comfortable with computers than faculty (4). Simulation (e.g., examinations with standardized patients), handhelds (data and algorithms), simulators (e.g., entire medical wards), pharmacy databases (e.g., ePocrates), telemedicine, and virtual reality (e.g., schizophrenia) (5—7) are ground-breaking but only insofar as they are carefully taught and fit within a broader curriculum. Having invested in computer systems that proved inefficient, many institutions have concerns about costs as well as uncertainty about how to proceed with change.
This article provides a brief overview of key issues for educators regarding medical education and technology, discussing how successful programs got started and the issues these programs faced. Principles of using computers to teach and options for assessment are summarized. Further, we define computer literacy—the processes of learning about computers, learning through computers, and applying technology to clinical care—to help readers learn how computers are successfully used and how the medical field can stay abreast of the latest technology. Model programs, tools, and resources are also reviewed.
Faculty, departments, and institutions are examining their mission and how it relates to technology and medical education. In the past, technology was unsuccessfully added to rather than incorporated as a core part of curriculum. Presently, the influence and impact of technology are so great that its place in the medical infrastructure must be assessed, including its fluency with other systems of education, clinical care, administration, and research. Input from current and future users is critical throughout this process, and educators must adapt technology to curricular content, teaching styles, and teaching methods.
The Association of American Medical Colleges (AAMC) Medical School Objectives Project and the General Professional Education of the Physician and College Preparation for Medicine Report (8) suggest integration of technology into the medical curricula, but most programs are struggling to achieve this. However, most programs are applying technology to clinical care (9). Students appear to understand the shortcoming, with only 37% considering themselves to be computer literate but 92% agreeing that technology should be taught in medical school (10).
One inroad of technology has been the personal digital assistant (PDA). The American Medical Student Association (AMA) reports that "possessing a PDA during the clinical years is now regarded to be nearly as essential as owning a stethoscope" (from http://www.amsa.org/resource/pda.cfm). In 1994, only 10% of medical students owned PDAs (11), and only recently have medical students received PDAs when they begin school. The number of physicians using PDAs is increasing, with "50% … as users by 2005 … as a point-of-care medical informatics tool" (from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt). The PDA, however, is only successful when students are taught how to use it (e.g., what programs to use, how it interfaces with other information systems).
A viable first step for institutions is to assess the needs and possibilities of informatics on multiple levels that include:
1. Infrastructure: hardware and software;
2. Connectivity of information between participants (students, staff, faculty, hospital and others);
3. The relationship of technology to the curriculum: technology to facilitate, "take over" and add to current programs (e.g., use of questionnaire data to guide instructional services in a computer-based instructional laboratory and via the Internet) (11) is faster and had better data integration than a program taught hands-on by faculty);
4. Computer literacy of all participants: knowledge, skills, behaviors and attitudes; and
5. A computer-based learning platform to chart and evaluate the learning path of an individual (e.g., Blackboard, Sakai), with integrated feedback to faculty.
There are many principles and methods for successful development of medical informatics programs for learning and clinical care (see a1). Initial assessment and follow-up quantitative (e.g., scores) and qualitative (e.g., attitudes) evaluations are crucial. A model institution has an integrated plan of assessing needs and tailoring resources, with feedback between students, teaching faculty, and administrators (11). Clinical, education, evaluation/research, and healthcare manager roles need better definition to support lifelong learning in technology by the student—teaching them how to access, evaluate, and use information resources (12).
Students in many fields prefer online services, wireless when possible, for flexibility and ease of learning. The integration of technology into a "real" curriculum is needed.
The process of teaching technology is as important as structure, content, or the tool of technology. For example, activities simulating how students will use technology on their own or later in practice are critical. This could be considered the problem-based learning (PBL) or case-based equivalent of technology education.
Content and process intervention is needed to achieve computer literacy and involves balancing student need, faculty expertise, administrative resources, and time in a curriculum (see a2). Students want to learn how to utilize medical applications (83%) and technology (44%) and how to effectively perform database searches (23%) (10).
To effectively use computers, one must first have some technical knowledge, conceptual understanding of their function, and awareness of information flow and linkage (see a2). Some students still need to learn the use of e-mail, software programs, and computer maintenance skills (e.g., security, data back-up). Information searching has also been an area of intense focus (guidelines) (13), with most schools teaching students software programs early on in order to prepare them to "learn with" the programs later.
Learning Through Computers
Once those basic computer literacy skills have been enhanced, there are many ways to learn through computers—simulators, virtual reality, tutorials, web-based curricula, and formative examinations. Most institutions use demonstrations, lectures, small-group tutorials, hands-on labs, and task-based assignments in years 1—3 of a curriculum. A review of e-learning practices revealed that 66% of studies discuss web-based systems, and 48% focus on outcomes for first- and second-year students (14). A computer may provide a clinical experience for students to augment clinical encounters, since the Liaison Committee on Medical Education (LCME) requires clerkship directors to expose all medical students to a uniform set of patient illnesses.
Computer-aided instruction is used by approximately 60% of students (11) and helps with skill acquisition at novice and intermediate levels for surgery (15). Such programs teach symptoms and diagnostic skills in preparation for clinical encounters.
Computers offer feedback to students in a variety of ways, from formative examinations to communication skills via an objective structured video examination (OSVE; 16). WebCT, front-end software for Internet-delivered material, became an integral part of a problem-based learning, student-centered curriculum (17). Success was dependent on many factors: training, clear goals linked to learner needs, quality of content with regular updates, user-friendly software, visual graphics, easy access, and evaluation (outcomes, feedback).
Opportunities to learn with computers are also extensive and may involve information searches (e.g., National Library of Medicine, MEDLINE, Micromedex, PubMed, Cochrane, Highwire) and programs to enhance clinical care (e.g., ePocrates). Presently, more emphasis is needed on processing rather than obtaining information. Diagnostic databases (e.g., Dermadex atlas) and decision-support programs are more accessible, and some are portable. Assessment of learner needs and preferences before purchase and implementation of programs is recommended to suit needs and goals.
Decision-support systems generally help with supplementing physician memory, memory retrieval, and automated decision making in situations that are predictable or routine (18). More complex decisions are supported by information retrieval but are ultimately dependent on clinician judgment. These technological resources change physician behavior and improve outcomes per self-report studies. As a result, adherence to guidelines is enhanced (18).
Handhelds have been endorsed by the Health Care Information and Management Systems Society (19) for communication, service administration (6), and clinical care. Databases for prescribing (e.g., iScribe and PocketScript) and documentation systems are commonly used (6, 20). PDAs, Pocket PCs, Tablet PCs with handwritten input, and other Windows-based PCs vary in terms of software operating systems, price, size/weight, display, expansion slots, connections with desktop, multimedia, file organization, and other software (6, 21—23).
Clinical information systems integrate patient information in an EMR with billing and administrative data; prompt physicians to initiate evaluations or treatment; and offer clinical pathways, protocols and guidelines (2). Preferences among users (e.g., patient, student, faculty, hospital administration and third party payers) need to be considered in order to increase the likelihood that such preferences will be employed.
Many applications are available for psychiatry and medical practice (see a3). Some help collect and process information (e.g., patient-information managers, logs to track clinical experience, tools to collect research data), and others provide information (e.g., practice guidelines, diagnostic tools) (24). Computerized decision-support systems are being evaluated with regard to learning styles (25) to improve "fit" with users. A skill set for use of video, telephone, e-mail, and other modalities may also be necessary if used extensively for patient care (7).
Selected Technology Tools, Models, and Programs
A collaborative academic network based on technology assists students, faculty, and institutions because it integrates materials, methods, and administration. Registration and grade book programs are examples of computer-based administration. A computer center may offer a support system with resources. E-portfolios organize the journals and learning tools specific to the learner, a course, or other tasks. A connection to faculty’s teaching materials, including syllabi, may be part of the network (e.g., My Info Vault).
Tools, models, and programs specific or applicable to medical and psychiatric education have also been highlighted for adoption (see a4). Other applications in medicine could be applied to psychiatry (see a3). It is time and cost-effective not to reinvent the wheel.
Several areas of advancement deserve special highlighting:
1. Workflow: Clinical (as above), educational programming (e.g., the Oasis online submission and review program requires) and peer review process for scientific and medical journals (Scholar One);
2. Data aggregation: Aggregation, integration and dissemination of educational and clinical data for larger scale analysis is possible for clinical and research purposes (e.g., Cochrane Library); and
3. Multi-site collaboration: Release of educational innovations for a standardized, international, online medical school curriculum (e.g., IVIMeds); peer-reviewed instructional materials, assessment materials, virtual patients, faculty development materials and educational standards (e.g., AAMC’s MedEd Portal); available, high-quality multimedia materials (e.g., The Health Education Assets Library).
Successful programs have the following in common:
1. Assessment of needs and skills at all levels (students, faculty, department and school);
2. Increased focus on skills and attitudes compared to knowledge;
3. Use of sound informatics principles and methods to implement programs (see a1);
4. Education on relating to technology (how it works, learning through/with it) (see a2);
5. Evaluation and application of existing resources to institution’s need (see a3); and
6. E-integration for a collaborative academic network (learning tools, evaluation, portfolios, libraries/resource centers and communication).
Learning about computers, learning with computers, and applying computers to care are key steps toward computer literacy for physicians. A balanced approach between content and process is necessary. Selection, application, and integration of technology require effort but may simplify work. New prototypes, models, and programs in technology enable learner-specific progress, flexibility, and significant integration through a collaborative learning environment. Interdisciplinary collaboration is necessary in the future, and more discussion is needed on the context for successful integration of technology in terms of faculty development, management of change, and securing funding.
The authors thank the following organizations: American Psychiatric Association (APA); American Psychiatric Publishing, Incorporated; Association for Directors of Medical Student Education in Psychiatry; Association for Academic Psychiatry; Association of American Directors of Psychiatry Residency Training; American Association of Chairs of Departments of Psychiatry; American Association of Medical Colleges; American Association of Technology in Psychiatry.
The authors also thank Nancy Delanoche, APA Office of Education; and Krisy Edenharder, Medical College of Wisconsin.